State Programs Face Challenges in Widening Access

David Pisani

Copyright 2002 Journal of the California Dental Association.

Access to dental services for many individuals remains an elusive health care benefit. For the low-income and uninsured, this means they may not be able to visit the dentist every year. According to some, the lack of access to dental services on a national level has reached critical proportions.

A recent University of Maryland study suggested that "Children enrolled in state Medicaid programs are less likely to visit the dentist than their peers with private insurance." The study further stated that of the children with Medicaid, "only 28 percent visited the dentist at least once a year; and among children with no insurance, only 19 percent had made at least one trip to the dentist." On the other end of the spectrum, 56 percent of their privately insured counterparts visited the dentist annually. The results of the University of Maryland study also suggest that further investigation is needed of the effectiveness of Medicaid dental programs, according to Dr. Richard J. Manski, the lead researcher.

In California, the Office of Medi-Cal Dental Services is responsible for the implementation of the state’s Medicaid dental program, known as Denti-Cal. California’s Department of Health Services jointly administers the Denti-Cal program with Delta Dental of California.

In addition to Denti-Cal, California has developed the Children’s Health Insurance Program known as the Healthy Families Program. The Healthy Families Program is administered by the California Managed Risk Medical Insurance Board and provides child-centered comprehensive benefits that include health, dental, and vision, provided at low monthly premiums to low-wage California families. Families that participate in the Healthy Families Program select their benefits from a variety of plans.

Uninsured children (ages 1-19) in families with incomes of less than 250 percent of the federal poverty level who are not eligible for no-cost Medi-Cal are eligible for Healthy Families benefits. All families participating in the Healthy Families Program pay monthly premiums that vary from $4 to $9 per month per child (depending on income and the number of children enrolled). There is also a monthly premium limit of $27 per month per family. In addition, families that prepay three months of premium are entitled to the fourth month free.

The current number of subscribers in the Healthy Families program totals 468,349, with the following ethnic breakdown:

* Hispanic/Latino -- 66.8%

* White -- 15.9%

* Asian/Pacific Islander -- 13.2%

* Black/African American -- 2.9%

As of 2001, the medical benefits portion of the Healthy Families Program has been evaluated, and a dental evaluation is planned for early 2002. Although many are encouraged by the goals of the Healthy Families Program, many are also concerned that the program is falling short, particularly in the area of sufficient provider networks to serve the targeted population. The upcoming dental evaluation may shed interesting light on the success of the dental benefits portion of the program.

Similarly, concerns are being raised as to the effectiveness of the Denti-Cal program in providing access to dental services for the state’s neediest individuals. Denti-Cal has an annual budget of $750 million and serves approximately 5 million beneficiaries.

As a result of these concerns and opportunity provided by the Health Insurance Portability Accountability Act requirements, the Office of Medi-Cal Dental Services has chosen to examine the Denti-Cal program. In doing so, the office has formed a unique partnership with the California Dental Association. This partnership known as the Denti-Cal Review Project was created for the purpose of conducting a thorough review of the Denti-Cal program.

As a main focus of this partnership, CDA and Denti-Cal officials planned and hosted a series of town hall meetings in six cities across the state. The purpose of these meetings was to solicit feedback from providers who participate in the Denti-Cal program as to how the program can be improved. In addition to dentists, participants included CDA component society executive directors, dental auxiliaries, local health department officials, public interest law advocates, beneficiaries, developmentally disabled program administrators, Women, Infants and Children staff, representatives from maternal and child health, children’s advocates, and other stakeholder groups.

The Denti-Cal town hall meetings provided a tremendous amount of information about strengths and weaknesses of the program. At each meeting, participants indicated that although the Denti-Cal program has many flaws, there are several aspects of the program that do work well. Among the program characteristics considered positive are the availability of emergency services for acute dental needs, no pre-authorization for children’s services, school-based prevention programs, and access to care for a large segment of the population. However, participants also indicated that the Denti-Cal program must be modified in many areas. Areas for improvement include the cumbersome nature of paperwork, fee schedules that remain too low, unnecessary pre-authorizations, inconsistency in regulations, poor patient compliance and a lack of case management services, routine denials, policies that seem to push practitioners toward medically unnecessary procedures in order to provide needed care (pulling teeth to place partials), lack of information communicated to providers and beneficiaries, and limitations on certain procedures. A set of recommendations was also developed at the end of each town hall meeting. These recommendations included the creation of an ongoing advisory group to plan, implement, and evaluate the changes made to the Denti-Cal program, the promotion of oral health as a critical aspect of primary health, increased provider participation, fee enhancements, and the use of best practices.

These meetings also served as a clear reminder that issues regarding the Denti-Cal program are very complicated, and the reasons for poor participation among dentists goes well beyond the issue of inadequate reimbursement for services.

The town hall meetings were completed in July and a final report was scheduled for release in late November 2001. This report was expected to include a summary of the town hall meetings, the process used for solicitation of information, individuals and groups who participated, and the complete set of recommendations on how the Denti-Cal program should be improved. The final report will then serve as the basis for an action plan that will attempt to implement the changes necessary to improve the program.

Author

David Pisani is CDA’s manager of policy development and analysis.